A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?

Unilateral joint involvement.

Ulnar deviation.

Decreased sedimentation rate.

Fractures of the spine.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Unilateral joint involvement is not typical of rheumatoid arthritis. This condition usually affects joints symmetrically, meaning both sides of the body are involved. Rheumatoid arthritis is an autoimmune disorder where the immune system mistakenly attacks the synovium, leading to inflammation and joint damage.

Choice B rationale

Ulnar deviation is a common finding in rheumatoid arthritis. It occurs due to chronic inflammation and damage to the joints, particularly in the hands. The fingers may deviate towards the ulnar side (the side of the little finger) due to the weakening of the ligaments and tendons.

Choice C rationale

Decreased sedimentation rate is not a typical finding in rheumatoid arthritis. In fact, the erythrocyte sedimentation rate (ESR) is usually elevated in this condition due to the ongoing inflammation. ESR is a marker of inflammation and is used to monitor disease activity.

Choice D rationale

Fractures of the spine are not a common finding in rheumatoid arthritis. While osteoporosis can be a complication of rheumatoid arthritis, leading to an increased risk of fractures, the spine is not typically the primary site of joint involvement in this condition.

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Correct Answer is ["A","B","E"]

Explanation

Wound infection is a significant risk factor for dehiscence. Infections can weaken the wound edges and delay healing, increasing the likelihood of the wound reopening.

Choice B rationale

Obesity is a risk factor for dehiscence because excess adipose tissue can place additional stress on the wound, impair blood flow, and delay healing.

Choice C rationale

Altered mental status is not directly associated with an increased risk of dehiscence. While it may affect a patient’s ability to follow postoperative care instructions, it is not a primary risk factor.

Choice D rationale

Pain medication administration is not a risk factor for dehiscence. Pain management is essential for recovery and does not contribute to wound reopening.

Choice E rationale

Poor nutritional state is a risk factor for dehiscence because adequate nutrition is essential for wound healing. Malnutrition can impair the body’s ability to repair tissues and increase the risk of wound complications.

A. Remove the vest daily to inspect the client’s skin integrity. B. Check that the halo jacket is snug against the client’s skin. C. Provide range of motion to the client’s neck. D. Monitor the client for an elevated temperature.

Correct Answer is D

Explanation

Choice A rationale

Removing the vest daily is not recommended as it can disrupt the alignment and stability provided by the halo fixation device.

Choice B rationale

The halo jacket should be snug but not too tight to avoid pressure sores and discomfort.

Choice C rationale

Providing range of motion to the neck is contraindicated as the halo fixation device is meant to immobilize the cervical spine.

Choice D rationale

Monitoring for an elevated temperature is crucial as it can indicate an infection, which is a common complication with halo fixation devices.

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A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury?

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